Specialty
ACL Tear Surgery
ACL reconstruction with patient-matched graft selection (quadriceps, hamstring, or BTB autograft), the BEAR implant for selected acute tears, and ACL+LET augmentation for high-risk pivot athletes — by Dr. Sabrina Strickland at NYU Langone Orthopedic Center in New York.
ACL tear surgery is reconstruction of the anterior cruciate ligament — the central knee stabilizer that prevents the tibia from sliding forward on the femur and that resists rotational shear during cutting and pivoting. Reconstruction uses a tendon graft (autograft from your own quadriceps, hamstring, or bone-patellar tendon-bone — or allograft from a donor) passed through anatomic tunnels in the tibia and femur and fixed with button-and-suture constructs. For carefully selected acute tears, the BEAR (Bridge-Enhanced ACL Restoration) implant supports healing of the patient's own ACL instead of replacement. For revision cases or high-risk pivot athletes, ACL+LET (anterolateral ligament) augmentation reduces re-tear rates. Concurrent meniscus repair or partial meniscectomy is performed in the same operation when needed. Return to cutting and pivoting sport is typically 6 to 9 months and is criteria-based, not calendar-based. Dr. Sabrina Strickland performs ACL reconstruction at NYU Langone Orthopedic Center in New York with a focus on graft selection matched to the patient and structured return-to-sport rehabilitation.
If you have torn your ACL, the question is rarely whether you can live with it — many patients can — but whether your activity goals require the rotational stability that the ACL provides. A patient whose goal is to return to running, cycling, and swimming has different decision-making than a patient whose goal is to return to soccer, basketball, lacrosse, skiing, tennis, dance, or martial arts. The cutting and pivoting demands of those sports require an intact ACL or a reconstructed one; without it, the knee will give way, the meniscus and cartilage will take wear over time, and the long-term cost is real even if the short-term function feels acceptable.
This page covers what the ACL is and what it does, how a torn ACL feels, when surgery is and is not necessary, the four main graft options and how they differ, the BEAR implant, ACL+LET augmentation for high-risk profiles, revision ACL surgery, the return-to-sport rehabilitation that actually works, and when a sub-specialty second opinion is worth seeking. For closely related topics, see meniscal tear (often torn alongside the ACL); sports injuries for the broader context of complex multi-ligament knee trauma; MACI cartilage repair and cartilage transplantation when the ACL injury has produced cartilage damage; and joint preservation and osteotomy when alignment correction is part of an ACL revision plan.
What the ACL Is and Does
The anterior cruciate ligament (ACL) is one of the four main ligaments of the knee, running diagonally inside the joint from the back of the femur to the front of the tibia. It does two essential things:
- Prevents the tibia from sliding forward on the femur (anterior translation)
- Resists rotational shear — the kind of force that occurs when the foot is planted and the upper body twists in the opposite direction
Without an intact ACL, the knee can still walk, run in a straight line, and tolerate most activities of daily living. What it cannot reliably do is cut, pivot, decelerate, or absorb the rotational loads of pivoting sport. An ACL-deficient knee in an athlete who continues to cut and pivot accumulates secondary damage to the meniscus and cartilage over time — this is one of the more important reasons that active patients who tear their ACL elect reconstruction even if the short-term symptoms are manageable.
How an ACL Tear Feels
The acute injury is usually distinct:
- An audible pop at the moment of injury — reported by the majority of patients
- Immediate inability to continue the activity
- Rapid swelling within the first few hours (a hemarthrosis — blood in the joint)
- A sense of giving way or that the knee "isn't right"
- Pain that is variable — some patients have severe acute pain, others have surprisingly mild pain that masks the severity
In the days and weeks after injury, swelling typically diminishes, and many patients can walk relatively normally. The chronic ACL-deficient knee often feels stable in straight-line activity but gives way when the patient tries to cut, pivot, or decelerate — particularly on uneven ground, going down stairs, or stepping off a curb at an angle. This recurrent giving-way pattern is what produces the meniscus and cartilage damage of an unreconstructed ACL deficiency over time.
Video: Dr. Strickland explains what to expect from ACL surgery (1:43).Transcript
The Surgery Decision
Whether to reconstruct an ACL depends on:
- Activity goals — cutting and pivoting sport (soccer, basketball, lacrosse, skiing, tennis, dance, martial arts) typically requires reconstruction; running, cycling, swimming may not
- Age — younger patients, particularly skeletally mature adolescents and young adults, more often benefit from reconstruction because of higher activity demands and longer expected duration of athletic participation
- Concurrent injuries — meniscus tears, particularly bucket-handle tears or root tears, often warrant surgery and the ACL reconstruction is performed in the same operation
- Symptoms — recurrent giving way despite bracing and physical therapy is a strong indication for reconstruction even in lower-demand patients
- Imaging — complete vs. partial tears, associated injuries on MRI
- Profession and specific demands — firefighters, military, law enforcement, manual laborers in physically demanding jobs often need reconstruction even outside competitive sport
Patients who are not surgical candidates — or who choose to proceed non-operatively — can be managed with bracing for higher-risk activity, structured PT focused on quadriceps and hip strengthening, neuromuscular control work, and careful activity selection. Long-term outcomes in this group depend on how successfully the patient avoids cutting and pivoting demands.
Graft Selection — Four Options
Graft choice is one of the most important decisions in ACL surgery. All four options below are well-evidenced and produce excellent outcomes when matched to the right patient.
Quadriceps tendon autograft
Harvested from the quadriceps tendon above the kneecap. Strong biomechanical profile, cylindrical graft shape, lower harvest-site morbidity than BTB. An option in larger patients or high-demand athletes willing to tolerate more quad rehab after surgery.
Hamstring tendon autograft
Harvested from the semitendinosus and (sometimes) gracilis tendons. Avoids the patellar mechanism, well-tolerated, smaller incisions. A good option especially with LET augmentation in a wide range of patients who want to avoid anterior knee pain.
Bone-patellar tendon-bone (BTB) autograft
Harvested from the central third of the patellar tendon with bone blocks at each end. Provides bone-to-bone healing, historically considered the "gold standard" for high-demand pivot athletes. Trade-off: higher rates of arthritis and more anterior knee pain at the harvest site, particularly with kneeling.
Allograft (donor tissue)
Cadaveric tendon. Avoids harvest-site morbidity, shorter operative time. Higher re-tear rates than autograft in young high-demand patients, so typically reserved for lower-demand patients, multi-ligament reconstructions, and revision cases where autograft tissue is limited.
The choice is individualized to the patient's age, sport, anatomy, prior tendon issues, and personal preferences after a frank discussion of trade-offs. There is no single "best" graft for every patient.
Video: Dr. Strickland on her preferred ACL reconstruction technique (1:31).Transcript
The BEAR Implant
BEAR (Bridge-Enhanced ACL Restoration) is an FDA-approved implant that supports healing of the patient's own ACL rather than replacing it with a graft. It is a collagen-based scaffold placed between the torn ends of the ACL with a small amount of the patient's own blood — the implant supports the body's natural healing response and serves as a bridge for the ACL ends to heal across.
BEAR is appropriate for selected patients with:
- Acute ACL tears — typically within 50 days of injury
- Adequate ACL stump tissue on MRI
- Tear pattern that allows for the implant to bridge the gap
- Otherwise straightforward case without complex concurrent injuries that would override the BEAR plan
For appropriately selected patients, BEAR offers an alternative to traditional graft-based reconstruction without the harvest-site morbidity of autograft. Suitability is determined at consultation based on tear pattern, timing from injury, and patient factors.
ACL+LET Augmentation
The anterolateral ligament (ALL) is a structure on the outer side of the knee that contributes to rotational stability. Adding a small lateral extra-articular reconstruction to the standard ACL reconstruction provides additional rotational control. This combined ACL+LET approach has been shown in published studies to reduce re-tear rates in high-risk populations.
ACL+LET augmentation is considered for:
- Revision ACL reconstruction — where re-tear risk is already elevated
- High-grade pivot shift on examination
- Young female pivot athletes — a population with documented higher re-tear rates
- Generalized ligamentous laxity (knee hyperextension)
- Sports with the highest cutting and pivoting demands — particularly competitive soccer, basketball, lacrosse, skiing
The augmentation adds limited additional operative time and does not significantly change the recovery profile but adds meaningful rotational protection in the right patients.
Revision ACL Reconstruction
Revision ACL reconstruction — for patients whose primary ACL reconstruction has failed — is technically more demanding than primary ACL reconstruction. Causes of failure include traumatic re-injury, tunnel malposition (most common cause of "atraumatic failure"), graft fixation issues, biological failure, and unaddressed concurrent injuries (meniscus, cartilage, alignment).
Revision planning may include:
- CT scan to evaluate prior tunnel positions and bone stock
- Standing alignment films — varus alignment is a risk factor for ACL graft failure and may require concurrent or staged osteotomy
- Decision on single-stage vs. two-stage — if prior tunnels are malpositioned and overlap the planned new tunnels, bone grafting and a staged revision may be needed
- Graft selection — often a different graft than was used the first time, particularly when the prior graft was an autograft
- ACL+LET augmentation — commonly added for revision cases given the elevated re-tear risk
- Concurrent meniscus and cartilage work — addressing damage that has accumulated in the failed-ACL knee
Concurrent Meniscus and Cartilage Work
ACL injuries rarely happen alone. Concurrent meniscus tears occur in a substantial percentage of acute ACL injuries; lateral meniscus tears are particularly common in acute ACL injuries, while medial meniscus tears are more common in chronic ACL deficiency. Cartilage damage can occur from the initial injury impact ("bone bruise" pattern) or from chronic instability.
Whenever possible, concurrent injuries are addressed in the same operation as ACL reconstruction:
- Meniscus repair for repairable tears in the vascular zone — the well-vascularized environment of an acute ACL reconstruction enhances healing
- Partial meniscectomy for irreparable inner-zone tears, performed conservatively
- Cartilage repair (microfracture, MACI biopsy followed by staged implantation, or osteochondral procedures) when focal cartilage damage is present
- Multi-ligament reconstruction for combined ACL + MCL, ACL + posterolateral corner, or ACL + PCL injuries
For the dedicated walk-through of meniscus surgical decision-making, see meniscal tear. For cartilage repair after ACL injury, see MACI cartilage repair.
Prehabilitation Matters
The single most under-discussed factor in ACL outcomes is what happens before surgery. Patients who arrive at surgery with full range of motion, minimal swelling, and good quadriceps activation have substantially better post-operative outcomes than patients who arrive with a stiff, swollen knee and inhibited quadriceps. Prehabilitation includes:
- Range of motion restoration — particularly full extension
- Effusion control
- Quadriceps activation — early termination of quadriceps shutdown reduces post-op recovery time
- Education on the post-operative protocol so the patient hits the ground running
For most patients, this means several weeks between the injury and the operation — not because surgery should be delayed unnecessarily, but because the knee benefits from being well-prepared for it. The exception is irreducible mechanical block (e.g., a locked bucket-handle tear) or other situations that warrant earlier intervention.
What to Expect on Surgery Day
ACL reconstruction is performed as an outpatient procedure — you go home the same day. This is the typical patient experience and your specific protocol is reviewed at consultation:
- Arrival and pre-op — you arrive a couple of hours before the procedure for intake, change into a gown, and meet the anesthesia team
- Anesthesia consultation — the anesthesiologist reviews your history and discusses the anesthesia plan. For Dr. Strickland's ACL reconstructions, this is typically regional anesthesia (a spinal block with sedation) rather than general anesthesia. During surgery, a periarticular block is also placed around the knee joint to help reduce pain during the first day after surgery as part of an opioid-sparing pain protocol.
- Surgery — the procedure itself typically takes 1 to 2 hours depending on graft choice and any concurrent meniscus or cartilage work
- Recovery room — you wake up in the recovery area; physical therapy starts the same day with crutch training and basic motion
- Going home — you go home with crutches, a brace, ice, prescribed pain medication, and clear written instructions. A responsible adult must drive you home
- First 48 hours — ice, elevation, prescribed medications, gentle motion as instructed. The first week's focus is effusion control and quadriceps activation
Return-to-Sport Rehabilitation
ACL rehabilitation is a structured 6 to 12 month program. Return to sport is criteria-based, not calendar-based — the date matters less than the limb symmetry, hop testing, and psychological readiness benchmarks.
| Phase | Timeline | Goals |
|---|---|---|
| Phase 1: Protection and motion | Weeks 0–2 | Effusion control, full extension, quadriceps activation, weight-bearing as tolerated with crutches |
| Phase 2: Range and early strength | Weeks 2–6 | Full range of motion, off crutches, stationary cycling, early strengthening |
| Phase 3: Strengthening | Months 2–4 | Progressive resistance training, single-leg work, low-impact cardio |
| Phase 4: Running and plyometrics | Months 4–6 | Graduated running program, jumping and landing mechanics, change-of-direction drills |
| Phase 5: Sport-specific | Months 5–7 | Cutting, pivoting, deceleration patterns specific to the patient's sport |
| Phase 6: Return to sport | Months 6–9 | Limb symmetry index >90%, normal hop testing, psychological readiness, sport-specific clearance |
The biology drives the floor of the timeline — the graft needs time to revascularize and remodel into mature ligament tissue. The patient drives whether the timeline is met or pushed later. Patients who skip phases or who return to sport without meeting return-to-sport criteria have higher re-tear rates than patients who follow the structured progression.
Video: Dr. Strickland on rehabilitation and the techniques used to help prevent ACL retear (1:23).Transcript
Risks of ACL Surgery
ACL reconstruction is a well-established surgery with predictable outcomes for most patients, but no surgery is risk-free. The risks reviewed at consultation include:
- Graft re-tear — the most clinically relevant long-term risk, particularly for young high-demand pivot athletes. Re-tear rates are reduced with autograft over allograft in young athletes, with anatomic tunnel placement, with ACL+LET augmentation in high-risk profiles, and with structured return-to-sport rehabilitation that meets objective criteria before clearance
- Persistent stiffness or loss of motion — including cyclops lesion (a small scar nodule that can block extension). Reduced by good prehabilitation, early focus on full extension, and structured PT
- Infection — uncommon but a serious complication if it occurs
- Blood clot (DVT or pulmonary embolism) — risk is mitigated by early mobilization and individualized prophylaxis
- Graft impingement or fixation issues — rare with anatomic tunnel placement
- Harvest-site morbidity — with autograft only. Anterior knee pain (BTB), posterior thigh weakness or numbness (hamstring), or quadriceps weakness (quadriceps tendon)
- Anesthesia-related risks — including nausea, sore throat, rare allergic reactions to anesthetics, transient nerve irritation from the regional block
- Incomplete return to prior performance — some patients do not return to their prior level of sport even with a technically excellent reconstruction; psychological readiness, body composition changes, and time away from sport all contribute
The specific risk profile for your case depends on your age, activity level, graft choice, concurrent injuries, alignment, and any prior surgery on the knee. These are reviewed at consultation, and many of the risks above are modifiable by prehabilitation, graft selection matched to the patient, and rehabilitation that follows the structured protocol.
Common Patient Concerns
The three concerns we hear most often before ACL surgery, with honest answers:
"How much will this actually cost me out of pocket?"
ACL reconstruction is medically necessary for symptomatic ACL deficiency in active patients and is covered by all major commercial insurance plans, Medicare, and most union and self-funded plans. Your out-of-pocket cost depends on your specific plan's deductible, coinsurance, in-network status of the surgeon, the facility (NYU Langone or affiliated), and the anesthesia group. Our team verifies benefits and reviews your estimated surgical fee out-of-pocket with you before surgery so there are no surprises. See Insurance and Cost below.
"Six to nine months of recovery feels impossible. I can't take that long off."
The 6 to 9 month timeline is to cutting and pivoting sport — not to most of normal life. Most patients drive within 4 to 6 weeks (right knee) or 1 to 2 weeks (left knee, automatic transmission), return to desk work within 1 to 2 weeks, return to manual or active work over 2 to 4 months depending on the demands, and return to running between months 4 and 5. The long timeline only applies to the rotational and impact-loading sports that the ACL specifically protects against. Skipping the timeline does not save time — re-tear in the first year is a setback that costs far more than the structured rehab.
"I'm scared of pain and of getting hooked on opioids."
Dr. Strickland's ACL recovery protocol uses multimodal pain management — including a periarticular block placed around the knee joint during surgery to help reduce pain during the first day after surgery, scheduled non-opioid medications (acetaminophen and an anti-inflammatory unless contraindicated), ice, and elevation. Most patients use only a small number of opioid pills for breakthrough pain in the first few days, and many use none after the first 48 hours. The periarticular block and the multimodal approach are specifically designed to minimize the role of opioids in your recovery.
Insurance and Cost
ACL reconstruction is covered by all major commercial insurance plans, Medicare, and most self-funded and union plans when the diagnosis and indication for surgery meet medical-necessity criteria. The variables that drive your specific out-of-pocket cost are:
- Your plan's deductible and coinsurance — the structure of cost-sharing differs significantly between plans
- In-network vs. out-of-network status — for the surgeon, the facility (NYU Langone or affiliated outpatient surgery center), and the anesthesia group
- The bundled vs. separate billing for the surgeon, facility, anesthesia, imaging, physical therapy, and any concurrent procedures (meniscus repair, cartilage work)
- Out-of-network benefits — if you have them and choose to use them; we are happy to provide the codes you need to verify your benefits in advance
Before surgery, our office verifies your benefits, obtains pre-authorization where required, and reviews the estimated surgical fee out-of-pocket with you. If your plan doesn't cover a specific aspect (some biologics or out-of-network components), we discuss it openly before the operation, not after.
For benefits verification or to discuss self-pay arrangements, call us at 646-904-4664 or contact the office.
When to Seek a Sub-Specialty Second Opinion
A sub-specialty second opinion is particularly worth seeking when:
- You are a young athlete facing a graft choice and want a clear discussion of trade-offs
- You have an acute ACL tear and want to know whether you are a BEAR implant candidate
- You have a complex injury — ACL plus meniscus root tear, ACL plus cartilage damage, ACL plus MCL or posterolateral corner, multi-ligament knee
- You have a failed prior ACL reconstruction and are facing revision
- You are a female pivot athlete and want to know whether ACL+LET augmentation is appropriate for you
- You are past the typical age for ACL reconstruction and are weighing reconstruction vs. activity modification
- You have recurrent giving way after a non-operative trial and want to revisit the surgery decision
Frequently Asked Questions
Most patients return to cutting and pivoting sport 6 to 9 months after ACL reconstruction. Structured physical therapy is required for the entire interval. The graft needs that time to develop a blood supply (revascularize) and remodel into mature ligament tissue strong enough to withstand the loads of sport. Return-to-sport timing is criteria-based, not calendar-based — limb symmetry index, hop testing, and psychological readiness all matter as much as the date on the calendar.
Autograft uses the patient's own tendon (quadriceps, hamstring, or bone-patellar tendon-bone). It is preferred for young, high-demand athletes — re-tear rates are lower than with allograft in this population. Allograft uses donor tissue, allows shorter operative time, and avoids harvest-site morbidity — it is often a reasonable choice for older or lower-demand patients. Choice of graft is one of the more important decisions in ACL surgery and depends on age, activity level, and anatomy.
All three are well-evidenced and produce excellent outcomes when matched to the right patient. Quadriceps tendon autograft has gained ground in recent years for its strong biomechanical profile and lower harvest-site morbidity than BTB. Bone-patellar tendon-bone (BTB) provides bone-to-bone healing at both ends and is favored in some high-demand athletes — at the cost of more anterior knee pain in the harvest site. Hamstring tendon (semitendinosus and gracilis) avoids the patellar mechanism and is well-tolerated. The choice is individualized to the patient.
Not always. Patients whose primary goal is running, cycling, swimming, and other straight-line activities may do well with physical therapy, bracing, and activity modification. Patients who want to return to cutting and pivoting sports — soccer, basketball, lacrosse, skiing, tennis, dance, martial arts — usually need ACL reconstruction to restore stability and protect the meniscus and cartilage from the wear that occurs in an unstable knee.
BEAR (Bridge-Enhanced ACL Restoration) is an FDA-approved implant that supports healing of the patient's own ACL rather than replacing it with a graft. It is a collagen-based scaffold placed between the torn ends of the ACL with a small amount of the patient's own blood — the implant supports the body's natural healing response. BEAR is appropriate for selected acute ACL tears (typically within 50 days of injury) with adequate ACL stump tissue.
The anterolateral ligament (ALL) is a structure on the outer side of the knee that contributes to rotational stability. ACL plus LET augmentation adds a small lateral extra-articular reconstruction to the standard ACL reconstruction to provide additional rotational control. It is considered for revision ACL cases, high-grade pivot shift on exam, young female pivot athletes, generalized ligamentous laxity, and other high-risk profiles for re-tear.
Yes, in most cases. Patients begin walking with crutches immediately and progress to weight-bearing as tolerated within the first week. Stationary cycling typically starts in the first week. Crutch use is reduced over the first 2 to 3 weeks as quadriceps activation returns and gait normalizes. Concurrent meniscus repair or osteotomy may delay weight-bearing — those protocols are individualized.
Risks include graft re-tear (the most relevant long-term risk in young athletes), persistent stiffness or loss of motion (cyclops lesion), infection, blood clot, graft impingement, harvest-site pain (with autograft), and incomplete return to prior performance. These are reviewed at consultation, and several of them are reduced with appropriate prehabilitation, graft selection, anatomic tunnel placement, and structured rehabilitation.
Access & Office Location
Dr. Strickland sees ACL patients at one office, which works with patients traveling in from outside the immediate area:
- New York City: NYU Langone Orthopedic Center, 333 East 38th Street, 4th Floor, New York, NY 10016. In Midtown Manhattan, accessible from Manhattan, the outer boroughs, Long Island, Westchester, and northern New Jersey via the Queensboro and Triboro bridges and the FDR Drive. Phone: 646-904-4664.
For patients traveling to New York from out of state for sub-specialty ACL care, we coordinate consultation and surgery scheduling to minimize travel and align with imaging review and pre-operative work-up. Many out-of-state patients travel to NYU Langone specifically for revision ACL, BEAR candidacy evaluation, and complex multi-ligament knee reconstruction.
Patient Outcomes
The point of all of the above — graft selection, BEAR consideration, LET augmentation, structured rehab — is to get the right patient back to the activity that matters to them. The video below is one of Dr. Strickland's ACL patients sharing her return to sport after reconstruction.
Video: Denise's return to activity after ACL reconstruction with Dr. Strickland (1:55).Transcript
For more patient outcomes, see Dr. Strickland's success stories, including Denise's full story, returning to climbing after an ACL tear, and a skier with combined ACL and meniscus injuries.
Related Specialty Care
For meniscus tears that are commonly torn alongside the ACL, see meniscal tear. For broader sports trauma context including multi-ligament knee injuries, see sports injuries. For cartilage repair after ACL injury when focal cartilage damage is present, see MACI cartilage repair and cartilage transplantation. For alignment correction in revision ACL cases with varus alignment, see joint preservation and osteotomy.
Medical Disclaimer. This content is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Surgical and non-surgical orthopedic care should always be discussed with a board-certified orthopedic surgeon who has reviewed your imaging, history, and physical examination. Individual outcomes vary based on diagnosis, anatomy, comorbidities, graft choice, surgical technique, and adherence to rehabilitation. The general descriptions of anesthesia, pain protocols, and timelines on this page reflect typical ACL-reconstruction patient experience — your specific protocol is determined at consultation.
Discuss Your ACL Reconstruction
If you have an acute ACL tear and want to discuss graft selection or BEAR candidacy, or if you are facing revision ACL or a complex multi-ligament injury, bring your imaging to a sub-specialty consultation at NYU Langone in Midtown Manhattan.